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Blood Borne VirusesBlood Borne Viruses
Rob HaleRob Hale
Consultant in Special Care Consultant in Special Care DentistryDentistry
King’s College London Dental King’s College London Dental InstituteInstitute
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Blood Borne VirusesBlood Borne Viruses
VirusesViruses– HBVHBV– HCVHCV– HIVHIV
StatisticsStatistics– GeneralGeneral– PrisonPrison
Occupation exposuresOccupation exposures Oral health care IssuesOral health care Issues
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Hepatitis BHepatitis BVirusVirus
First isolated in 1969First isolated in 1969Virions known as “Dane particles” Virions known as “Dane particles” Hepadna virus with circular DNA Hepadna virus with circular DNA genomegenome
Clinical featuresClinical featuresincubation period of 2-5 monthsincubation period of 2-5 monthsinsidious onset insidious onset asymptomatic infections can occurasymptomatic infections can occursymptoms may includesymptoms may include
short, mild flu-like illnessshort, mild flu-like illnessnausea, vomiting, nausea, vomiting,
diarrhoeadiarrhoealoss of appetite, weight loss of appetite, weight
losslossjaundice, itchy skin, jaundice, itchy skin,
muscle muscle pain, arthralgia, rashpain, arthralgia, rash
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Hepatitis BHepatitis B
PathogenesisPathogenesis
infection transmitted infection transmitted parenterallyparenterally
virus replicates in liver virus replicates in liver
viral particles, surface protein viral particles, surface protein shed into bloodshed into blood
About 30% have no signs or About 30% have no signs or symptomssymptoms
Most patients with clinical Most patients with clinical hepatitis will recover hepatitis will recover completely with no untoward completely with no untoward long term effectslong term effects
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Hepatitis B - complicationsHepatitis B - complications1.1. Carrier statusCarrier status
HBV persists for > 6 monthsHBV persists for > 6 monthsdevelops in 5-10%develops in 5-10%carriage may persist up to 20 years and be asymptomaticcarriage may persist up to 20 years and be asymptomaticcarrier status more likely in:carrier status more likely in:
those who have received blood productsthose who have received blood productsthose co-infected with HDVthose co-infected with HDVthose with immune defectsthose with immune defects
2.2. Persistent infectionPersistent infectionApprox 5% fail to eliminate the virus completelyApprox 5% fail to eliminate the virus completelyThese at risk include – babies, young children, immunocompromised, These at risk include – babies, young children, immunocompromised, males>femalesmales>femalesongoing liver damage occurs because of host response against infected liver ongoing liver damage occurs because of host response against infected liver cellscells
Chronic infectionChronic infectionChronic persistent hepatitisChronic persistent hepatitisChronic active hepatitis – cirrhosis, liver failureChronic active hepatitis – cirrhosis, liver failure
Hepatocellular carcinomaHepatocellular carcinoma
Treatment for chronic HBV –Treatment for chronic HBV – InterferonInterferonLamivudineLamivudine
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Hepatitis B - serologyHepatitis B - serology
AntigensAntigens
Surface antigen Surface antigen ( HBsAg)( HBsAg)
virus replication is occurring in the virus replication is occurring in the liverliver
““e” antigen ( HBeAg)e” antigen ( HBeAg)high level of virus replicationhigh level of virus replicationhigh infectivityhigh infectivity
Core antigen ( HBcAg)Core antigen ( HBcAg)not found in bloodnot found in blood
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SerologySerology
Antibody responseAntibody response
Surface antibody (anti- HBs)Surface antibody (anti- HBs)Detectable late in convalescence, indicates immunity following infection, Detectable late in convalescence, indicates immunity following infection,
detectable for life, not found in chronic carriersdetectable for life, not found in chronic carriers
““e” antibody (anti-Hbe)e” antibody (anti-Hbe)Detectable as viral replication falls, indicates low infectivity in a carrierDetectable as viral replication falls, indicates low infectivity in a carrier
Core IgMCore IgMRises early infection and indicates recent infectionRises early infection and indicates recent infection
Core IgGCore IgGRises soon after IgM, present for life in chronic carriers and those who clear Rises soon after IgM, present for life in chronic carriers and those who clear
the virus , indicates exposure to HBVthe virus , indicates exposure to HBV
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Hepatitis B - preventionHepatitis B - prevention Active immunisationActive immunisation
– Serum derived Serum derived – Recombinant Recombinant
Three doses induces protective level of antibodies Three doses induces protective level of antibodies Vaccines should be administered toVaccines should be administered to– healthcare workershealthcare workers– sexual partners of chronic carrierssexual partners of chronic carriers– infants of HBV carrier mothersinfants of HBV carrier mothers
Passive antibodyPassive antibodyHep B immune globulin administered to non immune individuals Hep B immune globulin administered to non immune individuals
following single exposure to Hep b infected bloodfollowing single exposure to Hep b infected blood i.e. Needle stick injuriesi.e. Needle stick injuries
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Hepatitis CHepatitis CVirusVirus Togavirus with single stranded RNATogavirus with single stranded RNA six genotypes identifiedsix genotypes identified responsible for most cases of “non-A, non B hepatitis”responsible for most cases of “non-A, non B hepatitis” ranks second only to alcoholism as cause of liver damageranks second only to alcoholism as cause of liver damage
Clinical featuresClinical features incubation period of 6-8 weeksincubation period of 6-8 weeks causes a milder form of acute hepatitis than HBVcauses a milder form of acute hepatitis than HBV No signs or symptoms for many on infectionNo signs or symptoms for many on infection Mild, flu-like illness, nausea, vomiting, loss of appetite, weight Mild, flu-like illness, nausea, vomiting, loss of appetite, weight
loss, jaundiceloss, jaundice Many individuals develop chronic infection following exposureMany individuals develop chronic infection following exposure
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Hepatitis CHepatitis C
Infection transmitted parenterallyInfection transmitted parenterally
About 20% of individuals will clear the virus within 6 months About 20% of individuals will clear the virus within 6 months but this does not mean they are immune from future but this does not mean they are immune from future infectioninfection
80% will develop chronic hepatitis C infection – remain lifelong 80% will develop chronic hepatitis C infection – remain lifelong carriers/infectiouscarriers/infectious
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Hepatitis CHepatitis C
ComplicationsComplications
Chronic hepatitisChronic hepatitis
Liver cirrhosisLiver cirrhosis
Liver failureLiver failure
Liver cancer Liver cancer (<3%)(<3%)
TreatmentTreatment
InterferonInterferon
RibavirinRibavirin
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HIV/AIDSHIV/AIDS
HIVHIV
Human immunodeficiency virusHuman immunodeficiency virus
AIDSAIDS
Acquired immunodeficiency syndrome Acquired immunodeficiency syndrome
What’s the difference?What’s the difference?
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HIVHIV
RNA virus
Reverse transcriptase
Transmitted parenterally
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HIV antibody testHIV antibody test
ELISAELISA
Western blotWestern blot
A positive test A positive test indicates:indicates:
Exposure to the Exposure to the virusvirus
Persistent infectionPersistent infection InfectiousnessInfectiousness
It does not indicate It does not indicate AIDSAIDS
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HIV ProgressionHIV Progression
Becoming HIV antibody positiveBecoming HIV antibody positive Seroconversion illnessSeroconversion illness Asymptomatic HIV infectionAsymptomatic HIV infection Symptomatic HIV infectionSymptomatic HIV infection AIDS diagnosisAIDS diagnosis
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Medical monitoringMedical monitoring
FBCFBC
CD4CD4– 600- 1600 600- 1600
cells/mm3cells/mm3
Viral loadViral load
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Medical MonitoringMedical Monitoring
CD4CD4 Monitors immune systemMonitors immune system Help decide when to start therapyHelp decide when to start therapy Monitor effectiveness of drugsMonitor effectiveness of drugs
Viral LoadViral Load Identifies number of HIV particlesIdentifies number of HIV particles Help decide when to start therapyHelp decide when to start therapy Monitors effectiveness of drugsMonitors effectiveness of drugs
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MedicationMedication
Highly active antiretroviral therapy Highly active antiretroviral therapy (HAART(HAART– Reverse transcriptase inhibitorsReverse transcriptase inhibitors
Nucleoside analogues ( AZT,ddI, ddC, d4T)Nucleoside analogues ( AZT,ddI, ddC, d4T) Non-nucleoside analogues ( nevirapine)Non-nucleoside analogues ( nevirapine)
– Protease inhibitorsProtease inhibitors Saquinavir, Retonavir etcSaquinavir, Retonavir etc
Combination therapyCombination therapy
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Side effects of medicationSide effects of medication
TirednessTiredness Back painBack pain FeverFever NauseaNausea HeadacheHeadache VomitingVomiting DiarrhoeaDiarrhoea Abdominal painAbdominal pain Skin rashSkin rash
Changes in tasteChanges in taste Burning sensation of Burning sensation of
skinskin Muscle painMuscle pain Peripheral neuropathyPeripheral neuropathy Mouth ulcersMouth ulcers ConstipationConstipation InsomniaInsomnia LipodystrophyLipodystrophy
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Transmission of Blood Borne Transmission of Blood Borne VirusesViruses
Body fluidsBody fluids
RouteRoute
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TransmissionTransmission Blood/blood productsBlood/blood products
Organ donationOrgan donation
Sexual intercourseSexual intercourse
Artificial insemination with infected semenArtificial insemination with infected semen
Horizontal transmission Horizontal transmission
Vertical transmissionVertical transmission
Unknown – Hep CUnknown – Hep C
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StatisticsStatistics
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Hepatitis CHepatitis C Approx 191,000 individuals between 15-59 years with Approx 191,000 individuals between 15-59 years with
antibodies to Hep C in England & Wales in 2003antibodies to Hep C in England & Wales in 2003
Equates to approx 142,000 individuals with chronic Hep C Equates to approx 142,000 individuals with chronic Hep C infectioninfection
Approx 0.4% of general populationApprox 0.4% of general population
In Scotland, approx 50,000 infected of which 38,000 have In Scotland, approx 50,000 infected of which 38,000 have chronic infectionchronic infection
Northern Ireland approx 4000 individuals likely to be Northern Ireland approx 4000 individuals likely to be infectedinfected
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Hepatitis CHepatitis C
Difficult to estimate new infection rates Difficult to estimate new infection rates due to long time between infection and due to long time between infection and development of severe disease/deathdevelopment of severe disease/death
Increase in incidence until late 1980s Increase in incidence until late 1980s peaking at about 14,900 in 1988peaking at about 14,900 in 1988
Larger degree of uncertainty of Larger degree of uncertainty of estimates for later yearsestimates for later years
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Hepatitis CHepatitis C
Wide variation of HCV incidence in injecting drug Wide variation of HCV incidence in injecting drug users users
England England 3.01- 41.8%3.01- 41.8%
ScotlandScotland 11.9 – 28.4 % 11.9 – 28.4 %
Establishing contribution of this incidence to future Establishing contribution of this incidence to future prevalence of infection requires knowledge of IDU prevalence of infection requires knowledge of IDU populationpopulation
2004 study estimated between 100,000 – 150,000 2004 study estimated between 100,000 – 150,000 current injectors in England in 2000current injectors in England in 2000
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HIVHIV Estimated 77,400 persons living with HIV in UK by end of 2007Estimated 77,400 persons living with HIV in UK by end of 2007
During 2007 7,743 new diagnosesDuring 2007 7,743 new diagnoses– 55% heterosexual contact – majority acquired HIV abroad55% heterosexual contact – majority acquired HIV abroad– 41% MSM41% MSM
70% of persons seen for HIV care were receiving antiretroviral 70% of persons seen for HIV care were receiving antiretroviral therapytherapy
Almost one in five with severe immunosuppression were not on Almost one in five with severe immunosuppression were not on therapytherapy
Almost a third of persons newly diagnosed were diagnosed late Almost a third of persons newly diagnosed were diagnosed late – At a point at which therapy should have begun (CD4<200 )At a point at which therapy should have begun (CD4<200 )
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HIV and hepatitis in prisonsHIV and hepatitis in prisonsGlobally rates of HIV and hepatitis in prisons are higher than Globally rates of HIV and hepatitis in prisons are higher than
general populationsgeneral populations
HIVHIVEngland & Wales in 1997 – England & Wales in 1997 –
0.3% adult males, 1.2% adult females0.3% adult males, 1.2% adult femalesScotland in 1997 – Scotland in 1997 –
0.3% adult males, 0.6% adult females0.3% adult males, 0.6% adult females
Hepatitis CHepatitis CEngland & Wales in 1997 – England & Wales in 1997 –
9% adult males and 11% adult females9% adult males and 11% adult femalesScotland –Scotland –
8% adult males, 14.8% adult females8% adult males, 14.8% adult females
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HIV and hepatitis in prisonsHIV and hepatitis in prisons
Since 1997 prison population has increased Since 1997 prison population has increased by approx 29%by approx 29%
Has the number of prisoners infected with Has the number of prisoners infected with blood borne viruses also increased by this blood borne viruses also increased by this amount or more?amount or more?
Nature of prison populationNature of prison population Risks of transmission specific to prison Risks of transmission specific to prison
environmentenvironment
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Nature of prison populationNature of prison population
High risk for infection even before High risk for infection even before imprisonmentimprisonment
IV drug usersIV drug users 29% female, 24% male, 4% young offenders29% female, 24% male, 4% young offenders
>90% HCV infections are through IVDU>90% HCV infections are through IVDU
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Risks of transmission specific to Risks of transmission specific to prison environmentprison environment
IVDUIVDU
– One in five prisoners report having used heroin at One in five prisoners report having used heroin at some time whilst in prison (SSD/NAC 2005)some time whilst in prison (SSD/NAC 2005)
– Sharing of needles/equipmentSharing of needles/equipment
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Risks of transmission specific Risks of transmission specific to prison environmentto prison environment
Sexual activitySexual activity
– 2% of a sample of 208 prisoner participants had had 2% of a sample of 208 prisoner participants had had forced penetrative sexual intercourse (2004)forced penetrative sexual intercourse (2004)
– In a population of approx 75,000 – how many In a population of approx 75,000 – how many victims would that make!victims would that make!
– How many new infections?How many new infections?– Overcrowding, mental health problems, inadequate Overcrowding, mental health problems, inadequate
staff levels, absence of conjugal rights, homophobia, staff levels, absence of conjugal rights, homophobia, general intolerance, restriction of condomsgeneral intolerance, restriction of condoms
– Sexual behaviour in situation of intimidation and Sexual behaviour in situation of intimidation and violence – more risk of tearing and bleedingviolence – more risk of tearing and bleeding
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Risks of transmission specific to Risks of transmission specific to prison environmentprison environment
ViolenceViolence– Fights/assaultsFights/assaults– One in 10 men reported being assaultedOne in 10 men reported being assaulted– Gross under reportingGross under reporting– When bleeding occurs – may be low risk for HIV but greater for HCVWhen bleeding occurs – may be low risk for HIV but greater for HCV
TattooingTattooing– Sharing tattooing equipmentSharing tattooing equipment– 11% of study sample had been tattooed in prison11% of study sample had been tattooed in prison– Fifth of those who had been tattooed had been tattooed whilst in prison Fifth of those who had been tattooed had been tattooed whilst in prison
(Strang 1998)(Strang 1998)
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Occupational Occupational ExposureExposure
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Occupational Exposure
Since 1997 in UK:Since 1997 in UK:
3773 OE to blood or other high-risk body 3773 OE to blood or other high-risk body fluidfluid
1595 of these from London1595 of these from London
76% were percutaneous injuries76% were percutaneous injuries
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Occupational exposureRisk of infection following a percutaneous injury:Risk of infection following a percutaneous injury:
HBVHBV 1 in 31 in 3
HCVHCV 1 in 301 in 30
HIV HIV 1in 3001in 300Department of HealthDepartment of HealthHIV Prophylaxis : Guidance from the UK Chief Medical officers Expert Advisory Group on AIDS HIV Prophylaxis : Guidance from the UK Chief Medical officers Expert Advisory Group on AIDS September 2008From 2000-2007September 2008From 2000-2007
68% attributed to hollow bore needles68% attributed to hollow bore needles19% solid needles19% solid needles13% “other sharps” e.g scalpels, dental probes13% “other sharps” e.g scalpels, dental probesUnited Kingdom Surveillance of Significance Occupational Exposures to Blood Borne Viruses in Healthcare Workers 2008United Kingdom Surveillance of Significance Occupational Exposures to Blood Borne Viruses in Healthcare Workers 2008
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Occupational Exposure
Deep penetrating injuries with hollow bore Deep penetrating injuries with hollow bore needlesneedles
Device visibly contaminated with bloodDevice visibly contaminated with blood
Needle from source patient's artery or veinNeedle from source patient's artery or vein
Terminal HIV related illness in source patientTerminal HIV related illness in source patient
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Exposures to HCV,HIV HBVExposures to HCV,HIV HBV
VirusVirus Type of Type of exposureexposure
Total Total exposuresexposures
seroconversioseroconversionsns
Hepatitis CHepatitis C PercutaneousPercutaneous 1389 (37%)1389 (37%) 1212
MucocutaneousMucocutaneous 417 (11%)417 (11%)
HIVHIV PercutaneousPercutaneous 656 (17%)656 (17%) 55
MucocutaneousMucocutaneous 289 (8%)289 (8%)
Hepatitis BHepatitis B PercutaneousPercutaneous 242 (6%)242 (6%)
MucocutaneousMucocutaneous 54 (1%)54 (1%)
Co-infectedsCo-infecteds PercutaneousPercutaneous 212 (6%)212 (6%) 2 (HCV)2 (HCV)
MucocutaneousMucocutaneous 105 (3%)105 (3%)
All exposuresAll exposures PercutaneousPercutaneous 2855 (76%)2855 (76%) 1515
MucocutaneousMucocutaneous 902 (24%)902 (24%)
UnknownUnknown 16 (0%)16 (0%)
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Exposures to HCV, HIV, HBVExposures to HCV, HIV, HBV
Of 15 seroconversions in UK:Of 15 seroconversions in UK:
One dentist seroconverted to HCV One dentist seroconverted to HCV reported in 2001reported in 2001
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Key recommendationsKey recommendations Injuries with hollow bore needles remain most commonly Injuries with hollow bore needles remain most commonly
reported occupational exposure in healthcare settingreported occupational exposure in healthcare setting
HCV exposures remain greatest proportion of percutaneous HCV exposures remain greatest proportion of percutaneous exposuresexposures
HCWs exposed to HCV positive source patient still HCWs exposed to HCV positive source patient still not not receiving follow-up testing in line with national guidancereceiving follow-up testing in line with national guidance
No new HIV seroconversions since 1999No new HIV seroconversions since 1999
78% HCWs exposed to HIV positive source patient began PEP. 78% HCWs exposed to HIV positive source patient began PEP.
37% within an hour and 89% within 24 hours37% within an hour and 89% within 24 hours
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Post exposure prophylaxisPost exposure prophylaxis Truvada ( 300mg Tenofovir/200mg Emtricitabine) once a dayTruvada ( 300mg Tenofovir/200mg Emtricitabine) once a day
(nucleoside reverse transcriptase inhibitor)(nucleoside reverse transcriptase inhibitor)
2 Kaletra film-coated tablets ( 200mg Lopinavir/50mg 2 Kaletra film-coated tablets ( 200mg Lopinavir/50mg Ritonavir) twice a day Ritonavir) twice a day (protease inhibitor)(protease inhibitor)
PEP as soon as possible after exposure, ideally within an hour PEP as soon as possible after exposure, ideally within an hour following careful risk assessmentfollowing careful risk assessment
PEP now generally not recommended after 72 hours post PEP now generally not recommended after 72 hours post exposureexposure
Follow –up Follow –up 12 weeks after exposure12 weeks after exposureIf PEP taken for at least 12 weeks from when If PEP taken for at least 12 weeks from when
PEP PEP stoppedstoppedLonger follow-up for complex/co-infected casesLonger follow-up for complex/co-infected cases
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Side effectsSide effectsTruvadaTruvada
gastrointestinal disturbances gastrointestinal disturbances
(vomiting, abdominal pain, (vomiting, abdominal pain, faltualence, diarrhoea)faltualence, diarrhoea)
anorexia, pancreatitis, liver damageanorexia, pancreatitis, liver damage
dyspnoea, cough, headachedyspnoea, cough, headache
insomnia, dizziness, fatigueinsomnia, dizziness, fatigue
blood disorders (anaemia, blood disorders (anaemia,
neutropenia, thrombocytopenia)neutropenia, thrombocytopenia)
myalgia, arthralgia, rash, urticaria, myalgia, arthralgia, rash, urticaria, feverfever
Lypodystrophy, Lypodystrophy,
Kaletra
gastrointestinal disturbances gastrointestinal disturbances
(vomiting, abdominal pain, (vomiting, abdominal pain, faltualence, diarrhoea)faltualence, diarrhoea)
anorexia., hepatic dysfunction, anorexia., hepatic dysfunction,
pancreatitis,pancreatitis,
blood disorders (anaemia,blood disorders (anaemia,
neutropenia, thrombocytopenia)neutropenia, thrombocytopenia)
sleep disturbances, headache, sleep disturbances, headache,
dizziness, fatigue, parathesia,dizziness, fatigue, parathesia,
Myalgia, myositis, rhabdomyolysis,Myalgia, myositis, rhabdomyolysis,
taste disrturbances, rash, pruritis, taste disrturbances, rash, pruritis,
Steven-Johnsons syndrome, Steven-Johnsons syndrome,
lypodystrophylypodystrophy
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What if a healthcare What if a healthcare worker becomes worker becomes
infected?infected?
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Infected Health Care Infected Health Care WorkersWorkers
Seek confidential professional advice if Seek confidential professional advice if believe to have been exposedbelieve to have been exposed
Majority procedures in health care setting Majority procedures in health care setting pose no riskpose no risk
Those infected must seek expert medical Those infected must seek expert medical adviceadvice
Avoid exposure prone proceduresAvoid exposure prone procedures
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The majority of procedures in dentistry are The majority of procedures in dentistry are exposure prone exceptexposure prone except
Exam with mouth mirrorsExam with mouth mirrors Taking extra-oral radiographsTaking extra-oral radiographs Visual/digital exam of head & neckVisual/digital exam of head & neck Visual/digital exam of edentulous Visual/digital exam of edentulous
mouthmouth Taking impressions of edentulous Taking impressions of edentulous
mouthmouth Construction & fitting of full denturesConstruction & fitting of full dentures
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Oral Health CareOral Health Care
(Decontamination and (Decontamination and infection control – goes infection control – goes
without saying)without saying)
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Oral health careOral health care
HepatitisHepatitis
Drug metabolismDrug metabolism Bleeding tendenciesBleeding tendencies Liaise with liver physicianLiaise with liver physician PreventionPrevention
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Dental treatment for HIV Dental treatment for HIV antibody positive individualsantibody positive individuals
BleedingBleeding– ThrombocytopeniaThrombocytopenia
InfectionsInfections– NeutropeniaNeutropenia– Antibiotic prophylaxisAntibiotic prophylaxis
Wound healingWound healing
Local anaesthesiaLocal anaesthesia– Indinavir reactionIndinavir reaction
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Oral Manifestations of HIV Infection
Group 1Group 1 - Lesions strongly - Lesions strongly associated with HIV infectionassociated with HIV infection
Group 2Group 2 – Lesions less commonly – Lesions less commonly associated with HIV infectionassociated with HIV infection
Group 3Group 3 – Lesions seen in HIV – Lesions seen in HIV infection infection
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Lesions strongly associated with HIV infection
Candidiasis -Candidiasis - pseudomembranouspseudomembranouserythematouserythematous
Oral hairy leukoplakiaOral hairy leukoplakia Necrotising ulcerative gingivitisNecrotising ulcerative gingivitis Necrotising ulcerative periodontitisNecrotising ulcerative periodontitis Kaposi’s sarcomaKaposi’s sarcoma Non-Hodgkin’s lymphomaNon-Hodgkin’s lymphoma
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General ConsiderationsGeneral Considerations The principles of good oral health care are the The principles of good oral health care are the
same for patients with blood borne virusesas they same for patients with blood borne virusesas they are for all patients.are for all patients.
There is no justification for modifying dental There is no justification for modifying dental treatment based solely on status.treatment based solely on status.
Alterations may be indicated on the basis of Alterations may be indicated on the basis of medical problems that occur as a result of medical problems that occur as a result of infection.infection.
Consider each patient individually.Consider each patient individually.
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General ConsiderationsGeneral Considerations
Despite the immunological problems Despite the immunological problems resulting from HIV infection, few resulting from HIV infection, few complications from dental treatment have complications from dental treatment have been reported.been reported.
The successful management of any oral The successful management of any oral manifestations and good oral health care manifestations and good oral health care can improve the quality of life for the can improve the quality of life for the patient.patient.
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““Prisons are breeding grounds for blood-Prisons are breeding grounds for blood-borne viruses because they bring together borne viruses because they bring together a population with a disproportionate rates a population with a disproportionate rates of high-risk behaviours in overcrowded of high-risk behaviours in overcrowded and adverse conditions”and adverse conditions”
Dame Ruth RuncimanDame Ruth Runciman
National AIDS Trust ChairNational AIDS Trust Chair
Prison Reform Trust Deputy Chair Prison Reform Trust Deputy Chair
HIV and hepatitis in UK prisons: addressing prisoners’ healthcare needs(2005)HIV and hepatitis in UK prisons: addressing prisoners’ healthcare needs(2005)